Please fill in and print the form below then fax it to us at 910-762-0270
(All information is confidential and will never be sold or shared to any 3rd party.
It will be associated only to your account.)

First Name: Last Name: Billing Address: Address 1: City: State: Zip or Postal Code: Country: Daytime Phone: Shipping address if different from above: Address 2: City: State: Zip or Postal Code: Country: Daytime Phone:

ITEMS :

Qty: Item #: Item Name: Price:

Qty: Item #: Item Name: Price:

Qty: Item #: Item Name: Price

Qty: Item #: Item Name: Price:

Qty: Item #: Item Name: Price:

Qty: Item #: Item Name: Price

Qty: Item #: Item Name: Price :

Shipping and Handling Charges: Up to $20.00 $5.95 $75.01 - $85.00 $12.95 $20.01 - $30.00 $6.95 $85.01 - $100.00 $13.95 $30.01 - $45.00 $8.95 $100.01 - $200.00 $14.95 $45.01 - $60.00 $9.95 Over $200.00 10% $60.01 - $75.00 $10.95 Certain oversized, heavy or odd shape items Customer will be called if extra handling charges apply

Subtotal: 7% NC Sales Tax: Shipping & Handling: Total Due: